Foreword by Prof. Detlef Heidemann, DDS, Frankfurt, Germany 6 Foreword by Prof. Daniel Edelhoff, DDS, Munich, Germany 7
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1 CONTENTS contents Foreword by Prof. Detlef Heidemann, DDS, Frankfurt, Germany 6 Foreword by Prof. Daniel Edelhoff, DDS, Munich, Germany 7 1 SHAPE PERCEPTION STRUCTURE 1.1 The contours of shape Aspects of shape Texture and surface Surface structures 41 2 COLOR PERCEPTION 2.1 Analyzing features of color and structure Imaging using a mockup: The prospective variant Patient consultation: Visualization and confidence building 60 3 CREATIVE TOOLS 3.1 Instrumentarium and working materials Many parts make up the whole: Post-traumatic patchworking of an anterior tooth 67 4 METHODOLOGY FOR AESTHETIC REPAIR: SHADING AND LAYERING CONCEPTS 4.1 Methodology: Logical layering after dental structural analysis using digital image processing The two-color concept: Minimalism and performance The two-color concept: Opacity and transparency Systematics: Guidelines for recreating incisal color effects and morphology Incisal buildup: Step-by-step The incisal edge: A systematic reconstruction of morphology and function 94 5 COMPOSITE RESTORATIONS BY CLASSIFICATION 5.1 Cervical anterior crown restorations: Classification of the layering scheme according to chromatic aspects Wedge-shaped defects Multiple cervical lesions on anterior crowns Material composition with true-to-nature aestetics using flow materials Proximal anterior restorations Challenging proximal surfaces: Reconstruction of maxillary and mandibular anteriors Reconstructing proximal areas with opalescence Incisal anterior restorations Unilateral abrasion on the central incisor Aesthetic restoration of a fractured anterior tooth Personalizing incisal edges with opalescence 142 4
2 6 AESTHETIC REHABILITATION 6.1 Harmonizing a diastema and the vertical gingival height: Restorative widening of the emergence profile Diastemata: Restorative space closure Discoloration, retroinclination and devitality in the aesthetic zone Direct composite veneers for harmonizing the anterior dentition Veneers for aesthetic rehabilitation of tooth deformities An aesthetic alternative method for correcting moderately malpositioned teeth Designing natural anterior proportions Additional uses for composites: Residual substance, material properties and adhesion COMPOSITES AND FUNCTION Aesthetic and functional composite restorations THE PRACTICAL CONCLUSION A complicated, but inspiring patient case 250 Bibliographic and photographic references 263 NOTES TO THE READER Method of tooth notation The teeth described in this book have been numbered according to the two-digit system of tooth designation recommended by the World Dental Federation (Fédération Dentaire Internationale or FDI for short). 1 Used throughout the world, the FDI method makes visual, cognitive and computer sense. 2 According to the FDI two-digit tooth numbering system, the patient s mouth is divided into quadrants numbered from 1 to 4, clockwise, starting from the upper-right. The teeth are numbered from 1 to 8, going from the central incisor to the third molar. For example, in this book, the two maxillary central incisors are referred to as tooth 11 and tooth 21, respectively Peck S, Peck L. J Dent Educ. 1993; 57(8): List of manufacturers As a practical reference for readers and for better product accessibility, the product name, manufacturer's name and city are indicated in parentheses immediately following the term for products mentioned in the main text. 5
3 5.3 INCISAL ANTERIOR RESTORATIONS UNILATERAL ABRASION ON THE CENTRAL INCISOR 5 composite restorations This young woman was bothered by the distal incisal edge fracture of her tooth 21. Figures 141 to 158 illustrate how the disto-incisal edge of tooth 21 was built up. The shaping will then be critically evaluated taking morphological considerations into account Fig. 141 Fig. 142 Fig. 143 The distal incisal edge of tooth 21 of this patient was fractured and showed slight wear. The woman patient had always been bothered by the asymmetrical curve line of her incisal edges. However, after having heard about minimally invasive options, she decided at this point in time to have her substance defect restored. Compared to the laugh line, the missing distal corner of the incisal edge produced a discordant contour there. Analysis of the contours of the anterior teeth revealed a distally ascending curve of the incisal edges of the anterior tooth zones. However, this impression was created only because of the missing distoincisal edge. Although the loss of substance was relatively minor, the defect obviously produced a discordant relationship between tooth width and tooth length. This fact underscored the impact and functionality of the human perception. Any deviation in proportions of the teeth among each other is perceived as discordant, if not even distracting. Thus, it was understandable that, despite this apparently minor substance loss, the woman's aesthetic sensitivity was bothered enough by this defect to convince her to have it restored by a dentist. 134
4 Fig. 144 Fig. 145 Fig. 146 Fig. 147 On tooth 21, a provisional and diagnostic mockup was fabricated and tried in (see Chapter 3.2) under functional considerations. Next, a silicone impression was taken of the anterior teeth. The mockup was removed after the silicone material had hardened. As a control, the silicone matrix was pressed palatally onto the dental arch. The incisal edge area to be built up on tooth 21 was clearly visible. The tooth surface of tooth 21 was conditioned with etching gel (UltraEtch, Ultradent) and then bonded (OptiBond FL, KerrHawe). To isolate tooth 21, the adjacent tooth was covered with Teflon tape (the tape turned transparent from wetting with primer and bonder). A thin layer of transparent composite, shade T1 (Venus, Heraeus Kulzer) was placed in the silicone matrix, and pressed palatally onto the tooth with increasing pressure. Then, the composite was light-cured Fig. 148 Fig. 149 Fig. 150 Fig. 151 The hardened palatal shield comprised a delicate, primary and stable wall. The first layering component was an opaque dentin material A2 (Venus, Heraeus Kulzer) applied like mamelons (dentin tubules) on the shield. An enamel material with the shade Enamel A2 (Venus, Heraeus Kulzer) was layered over the dentin layer. A final layer of a translucent, cloudy effect material T2 (Venus, Heraeus Kulzer) was applied to mimic the brightness level of the natural tooth. 135
5 5 composite restorations Fig. 152 Fig. 153 Fig. 154 After the incisal edge of tooth 21 was finished and polished, its shade corresponded almost perfectly to the distal edge of tooth 11. A virtually invisible reconstruction was achieved. Even in the lateral view, it was obvious that the structures of the distal portion of the incisal edge descending into proximal area had been reconstructed realistically. When its interplay with the neighboring teeth was viewed from a greater distance, the restoration merged harmoniously into the arch. The proportions of the contour elements were concordant. With minimal therapeutic measures such as replacing a small portion of the disto-incisal edge, the initially uneven looking curve of the incisal edges in the maxilla was compensated to perfection. 136
6 Fig. 155 To check the quality and extent of the reconstructed, shape-determinant portions of tooth 21, ellipsoids were projected onto the tooth surface (see Chapter 2.1). This allowed comparison of the incisal edges of 11 and 21 with each other. Analysis of the blue geometrical figures revealed that the contours of the distal incisal edge of tooth 21 largely mirrored those of adjacent tooth 11. The oblique, ellipsoid form perfectly traced the curve of the disto-incisal edge of tooth 11, although a minor deviation was evident on tooth 21 (see arrow). Apparently, there was a little excess restoration left. Fig. 156 Under magnification, the excess portion of the restoration appeared slightly too large, but was not noticeable in the original size. Therefore, it was left as it was. Fig. 157 Close-up, the distinctive central incisors look virtually identical in terms of their shape. The shades of teeth 11 and 21 blended seamlessly into their surroundings. In this sense, the goal of "Restitutio ad integrum" was certainly accomplished everything was restored to its proper state! Fig. 158 The delighted woman directly after the treatment was concluded. Her harmonious lip and laugh line were successfully reconstructed. The asymmetry deriving from tooth 21 was eliminated and this attractive woman's little beauty flaw had disappeared. SUMMARY If the criteria for an anatomically correct shaping and contouring are met, small chromatic differences in layering will go unnoticed and will not detract from the overall quality of a restoration. In such a restoration, even the most critical observer will not notice the chromatic deviations at normal speaking distance. By contrast, an asymmetrical, obviously discordant appearing silhouette will always be perceived. 137
7 5.3.2 AESTHETIC RESTORATION OF A FRACTURED ANTERIOR TOOTH 5 composite restorations When reconstructing lost enamel and dentin, consideration must be given to morphological, functional and aesthetic aspects. If the contours and morphology of a tooth have been reconstructed according to an anatomical model, natural reflections are generated from areas on the tooth surface. Their harmonious lines testify to a suc Fig. 159 At the age of 19, the patient had sustained trauma to tooth 11 in a cycling accident. The fracture of the incisal edge had been restored with a veneer several years earlier. The patient felt that this reconstruction looked distracting and unattractive. Fig. 160 To better illustrated the challenge posed by the contours to be reconstructed according to the tooth's natural morpho - logy, the reflective areas of the definitive treatment outcome were highlighted using silver colored boxes. Fig. 161 Close-up of the inadequate filling on tooth 11. Discolored stains had built up at the interface between filling and tooth surface. The form, hue and chroma of this restoration were aesthetically unsatisfactory. Fig. 162 As part of the surface analysis, the anterior teeth were coated with silver powder to highlight the light reflection areas more intensely. The way the filling was built up did not correspond to the shape of the natural tooth surfaces and therefore looked out of place. Fig. 163 The palatal contour elements were supplemented to meet the anatomical prerequisites and the incisal region extended using a mockup. An impression of this buildup was taken with silicone to obtain a structural matrix of the desired form of the restoration to guide further treatment. Fig. 164 The old filling was removed, the margins of the cavity re-beveled and Teflon tape was wrapped around adjacent tooth 12 to isolate and protect it during the further conditioning process. 138
8 cessful, natural reconstruction. If the contours and morphology have been accurately incorporated into the tooth shape, the minute deviations in shade will not detract from a successful result. Figures 159 to 178 depict the treatment steps used for the aesthetic repair of an incisal edge on a patient who fractured it in a cycling accident [42] Fig. 165 Fig. 166 Fig. 167 Fig. 168 Fig. 169 Fig. 170 Etching gel (UltraEtch, Ultradent) was applied to tooth 11 and, after 15 to 20 seconds, rinsed off with water according to the manufacturer's instructions. A rough surface ( frozen surface ) was created at the etched areas of the preparation. After the surface of tooth 11 was bonded (OptiBond FL, KerrHawe) and the Teflon tape removed from the adjacent tooth, an opaque composite (Dentin A3 Venus, Heraeus Kulzer) was placed in the silicone matrix and pressed against the teeth from the palatal. Layering was extended up to the contact point of tooth 12, although the composite would not permanently bond with the surface of tooth 12 because it was not pre-conditioned. After removing the silicone matrix, a stable wall was available onto which the further layering components were applied. The next layer applied was a dentin material in the shade Dentin A 2 (Venus, Heraeus Kulzer). At this stage, the form was already being shaped, particularly towards the contact point of tooth 12 and the incisal edge. The layer after this consisted of the Enamel shade A2 (Venus, Heraeus Kulzer) which possessed a markedly high transparency. The labial form was not finalized yet in order leave enough room to apply the next layer for the color adaptation. 139
9 5 composite restorations Fig. 171 Fig. 172 Fig. 173 Fig. 174 Fig. 175 Fig. 176 The bright, milky effect material T1 (Venus, Heraeus Kulzer) in the final layer was used to mirror the disto-incisal brightening of tooth 21 onto tooth 11. According to the familiar procedure for a true-to-form finish, the tooth surfaces were coated once again with silver powder to check the result. The reflectance fields on the labial surfaces of the teeth were made prominent and conveyed an overall harmonious, pleasing impression. The filling contour of tooth 11 corresponded to the natural curvature of the labial surface and fit in with the overall symmetry. After the powder was removed and the surface polished to a high gloss, the light reflections were easily identifiable. They very strongly replicated the reflections off the adjacent tooth. Another photographic technique was used to judge how the colors were integrated. The flash was pointed at the tooth from another direction. This reduced the surface reflexes, allowing the color of the filling to be better scrutinized. Yet another perspective. Here, the marginal ridge was very easy to identify. It followed the distal contour of the tooth towards the proximal area and reflected the round design of the form. Further documentation of the reflectance fields on the labial surface, clearly proving that the objective to reconstruct a symmetrically aligned and anatomically defined natural surface texture of the filling had been accomplished. 140
10 Fig. 177 Fig. 178 Finally, the facial view of the restoration was reviewed. Silver powder clearly brought out all the reflected heights of contour and surfaces. The distal belly of tooth 11, shaped to create the proximal contact, was tapered into the incisal edge to open up the incisal triangle between teeth 11 and 12. This gave the tooth a very natural-looking tapered incisal region. The graphics projected onto the tooth surface provided information about the disto-incisal edge (blue) arranged as a mirror image. The transition to the filling was labeled with a white line. The incisal triangle was colored blue. The white stripes (labeled with blue lines on the graphic) depicted the spine formed by the labial surface and the surface elements descending into interproximal space. At the same time, they delineated the vertical reflectance fields. The transparent bluish ellipses were aimed to demarcate the disto-incisal zone. 141
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